20 january 2017 htp to uhc in iran, aht, tums 2016 · plan for training family physicians and...

20 January 2017 HTP to UHC in Iran, AHT, TUMS 2016

7th ANNUAL PUBLIC HEALTH SCIENTIFIC

CONFERENCE

13th –14th December 2016

Islam Abad, Pakistan

Amirhossein Takian MD PhD FHEA

Chair & Associate Professor

Department of Global Health and Public Policy

Health Transformation Plan to Reach Universal Health Coverage in Iran

by 2025

Iran - A brief Profile

• Total population 79,109,000 (2015) Urban 73 (%, 2013)

• Life expectancy at birth m/f 74/77 (years, 2015)

• Infant Mortality Rate 14 • Under five mortality rate 19 • Population Growth Rate 1.2% •

• Total expenditure on health per capita 1,082 (Intl $, 2015)

• Total expenditure on health as % of GDP 7.4 (2015)


Executive Structure of the Health System in Iran

MOHME

University of

Medical sciences

Director of district

health network School of …..

Teaching

Hospital

District Health

Center

District General

Hospital

Rural Community

Comprehensive Health Care

Center

Urban Community

Comprehensive Health Care

Center

Health

House

Health

House

Health

House

Health

House

Health

Post

Health

Post

Health

Post

Health

Post

Behvarz

Training Center

Health System Challenges (prior to HTP: May 2014)

• Incomplete and ineffective insurance coverage

• High share of out of pocket payment (50 to 58% 5 the year before HTP);

• Inadequate access to health services especially in remote areas;

• Undesirable citizens’ satisfaction due to quality of health care;

• Inadequate health workforces, infrastructures and financial resources;

• Unrealistic medical tariffs


Share of out‐of‐pocket expenditure in total health expenditure by

country group, 2010(WHO)

Group 3

50–80% Group 2

25–60% Group 1

12–19%


The Share of Main Payers from THE

WHO (Global Health Expenditure Database)


84%

?%

55%


Health Transformation Plan of 2014 (Goal and Objectives)

Goal of HTP

Achieving Universal Health Coverage by 2025

Objectives of HTP

•Improving financial risk protection;

•Increasing fair access to good quality health care;

•Upgrading the performance of health networks/facilities


o I.R. of Iran’s long standing commitment to UHC

o Launch of Health Transformation Plan, 05 May 2014 led by Minister of Health and Medical Education

HTP Essential Goals

Utilization

Equity of Access

Fairness in Financial

Contribution

Quality of Services

Funding of HTP

• Allocation of ADDITIONAL funding: 7.5 billion US$ over 2.5 years

• Sources of additional funding:

• 45% from targeted subsidies

• 35% from value added tax (VAT)

• 15% other sources


HTP interventions in Public Health: I

1. Providing primary health care (PHC modern health services) to villagers and cities under 20 thousand population and tribes; cities of 20 to 50 thousands population, as well as cities more than 50 thousand population and megacities.

2. Completing, developing and modifying family physician program and referral system in urban regions in two provinces of Fars and Mazandarn.

3. Promoting and development of national plan for self-caring

4. Reinforcing and institutionalizing programs for inter-sectoral cooperation

5. Strengthening public health programs (healthy water, safe food, healthy food regime, clean water)

HTP interventions in Public Health: II

6. Oral health program

7. National programs for prevention and control of Non-communicable diseases (NCDs) and risk factors

8. Population programs, reproductive health and child-bearing promotion

9. Nutrition program and modifying community nutrition model

10. Mental and social health promotion program

11. Reforming programs on prevention and control of communicable diseases, i.e. HIV and high risk behavior programs

12. Strengthening programs for health in natural and man-made disasters.

HTP Interventions in secondary care (1)

Fairness in Financial Contribution

Equity of Access Quality of Services

1.Reducing Out-of-pocket payment for in-patient services;

2.Providing basic health insurance to all citizens, particularly the poor;

3.Improving quality of hoteling in public hospitals;

4.Promoting normal vaginal delivery to bring C/S down;

5.Increasing the availability of specialist physicians in deprived areas.


HTP Interventions in secondary care (2)

Fairness in Financial Contribution

Equity of Access Quality of Services

6. Improving quality of outpatient services in public centers;

7. Developing pre-hospital emergency services including medicopters

8. Adjusting the relative value of health services in line with the market

9. Developing Pay for performance system to enhance providers’ motivation


MOF

MOHME

Supply side financing for

renovations “ hoteling”

quality OP services

Free NVD, reduce C. Section

24 hr specialist services

Ambulance services

Population/ copayment

3-6%

Subsidy for increased

tariff V2

SSO: employer/ employee/

government 6% payroll, 2 ×

minimum wage Cap

IHIO: MOH subsidize

premium for 11 m new

insured

Medical universities

Tertiary/ general

hospitals

Budget for payroll,

capital

Demand side

finance

Urban: comprehensive HC+

public/ private FP

Disbursement to hospital

through medical university for

the IP claim based on RVU in

tariff

Capitation payment 18/30 USD

per person per year from IHIO

Referral


Major achievements of HTP


Coverage & Financial Protection

Reducing the share of cost of hospitalization from 37% to…..

Reducing purchase of medicines, supplies and lab tests from 90% to …… 3%

8.5%

Price reduction in medical equipment 42%

19,500,000 Patients admitted to MOHME hospitals [2014] 10,677,000 New health insurance

77.4%

Increase financial protection against catastrophic costs in government hospitals (percent population)

From 58

to 40%

Reduce out of pocket spending from 52% in 2013 to ….


PHC and public health Increased Access of marginalized groups

916 health-posts and 17,000 new experts)

Pay for performance has been initiated EHSP has been amended with NCD screening PPP have been initiated at primary health care level

Plan for training family physicians and bridging programes for GPs

Deputy for Social Affairs established within MOHME to enhance inter-sectoral collaboration and SDGs’ implementation

HTP UHC by 2025 20 January 2017 HTP to UHC in Iran, AHT, TUMS 2016

Hospital based Care

Increased healthcare workforce

(6500 specialists for remote areas and 17000 new nurses and assistant recruited).

21,000 new hospital beds (Hospital beds/10000 increased from 15 to 17

Complete renovation of 30,000 hospital beds

Hospitalized patients in public hospitals pay only 6% and 3% of total hospital expenses as copayments in urban and rural areas, respectively

o Reduction in patients referral to purchase medicine and medical equipment from almost 100% to 3.2%

o 10.2% reduction of Cesarean rate; 470,000 NVD, free of charge

Improved access to drugs and medical devices in public hospitals

Most hospitals have initiated Quality Improvement programs and actively seek Accreditation

Improvement of Accident and Emergency services

Improvement of ECS helicopters and emergency units of the hospitals


Improving service inputs

Quality improvement for hoteling in public hospitals

• Reconstruction of bed space across 570 hospital

• Distribution of hoteling equipment

•Upgrading hospital beds

•Development and construction of Labor & Delivery Room in the 366 block of birth

2.0 million

m2

39,000

1,800

78000


After Before

Improving service inputs

Amin Hospital, Isfahan, Province Isfahan


Achievements Improving service inputs

In 19 specialties in 412 hospitals across 214 cities

7,200 5799 Specialists recruited in 338 hospitals in 301 deprived cities

100% Increased full-time specialists in remote areas from 5% to…..

658 Clinics with specialists in 385 Cities

16,852 Increased no. of Specialists in 577 hospitals to….

94 millions OP visits using public tariffs covered by insurance [in 2015]

24 hour availability of specialists in hospitals

Quality improvement for outpatient specialist visits

Availability of physicians in deprived areas


Improving service outputs

C/S Decreased by 6.5 % 6.5% 21 Operating air emergency sites

1,225,920 Normal vaginal delivery 5312 Transport of sick and injured during 3330 sorties

Promoting normal delivery Developing pre-hospital

emergency services (marine and medicopters)

360,000 Free education for 360,000 pregnant women


HTP improved financial protection Findings from two series of international independent evaluations (2015 & 16)


Year

Total health spending

% GDP

Public spending on

health % THE

Social security

funds % GGE

Private spending on

health %THE

OOP on health %THE

THE per capita

(PPP)

THE

per

capita (USD)

Public spending on health

% GGE HI coverage

rate

1995 3.6 44.8 45.0 55.2 53.6 288 68 6.2

2000 4.2 41.6 57.8 58.4 56.2 401 231 10.6

2005 5.7 38.1 45.8 61.5 54.9 738 176 9.9

2010 7.2 33.7 47.4 66.3 58.2 1231 448 12.7 77

2011 6.9 35.1 43.2 64.9 56.0 1233 521 13.0 79

2012 6.9 34.7 50.9 65.3 54.2 1155 344 16.4 83

2013 6.4 38.7 51.0 61.3 50.3 1054 313 16.4 82

2014 7.3 50.6 48.7 49.3 40.6 1276 390 10.8/23.6 83

2015 92


Insurance coverage has increased from 68% in 2007 to 92% in 2015

Note: membership is proxied by household payments to insurance schemes (ie. premiums) and employer/government contributions. Source: Household Income & Expenditure Survey


OOPS has remained relatively stable at approximately 2 million rials per person per year

Slight increase from 2014-15 is not statistically significant

Note: Figures reported in the 2015 WHO evaluation report were disaggregated and presented by quarter. Estimates presented here are pooled quarterly data and are therefore more representative for the entire year. Source: Household Income & Expenditure Survey

20 January 2017

HTP to UHC in Iran, AHT, TUMS 2016

The rich pay proportionally more out-of-pocket than the poor


Composition of OOP shows a proportional decrease in inpatient from 33% in 2007 to 22% of total OOP in 2015


Impoverishing health expenditures has also remained stable (or decreased) over the last two years

Source: Household Income & Expenditure Survey


Catastrophic health expenditures by equity stratifiers over time

Urban/Rural Quintile

Rural population are less financially protected although catastrophic has recently decreased

Poorest population groups are more financially protected although they may be foregoing care


Patients’ Satisfaction

73 88 89

74 78

78

74

56

77

48

56

62

55

78

70

62 62 67

39

48 46

40

46

57 72 63

70

51

0

20

40

60

80

100

Summer Autumn Winter Spring Summer Autumn

2014 (93) 2015 (94)

% S

ati

sfa

ctio

n

Patient

Physician (MOH)

Physician (Non-MOH)

Nurse (MOH)

Nurse (Non-MOH)

Patient Satisfaction is

acceptable (2014-2015)

78%


Challenges

• Sustainability of resources

• Open ended fee for service provider payment

• Insufficient attention to efficiency issues

• Lack of linkage and referral support to primary care

• Delayed payment to hospitals by insurance organizations

• Inadequate capacity of hospital managers

• Need for greater focus on quality and safety of services

• Low capacity of Monitoring and Evaluation activities


The remaining uninsured are the poor living in urban areas

Source: Household Income & Expenditure Survey


Ageing will Put Significant Cost Pressures on Iran’s Health and Pension Systems

Assuming 2030 and 2050 Iran Population Numbers and Distribution (Total Health Spending Increase in 2014 Sex/

Age

group

Relative

spending

weights

Males

0-18 0.54

19-44 0.49

45-64 1.36

65-84 2.49

85+ 4.41

Females

0-18 0.41

19-44 0.67

45-64 1.18

65-84 2.03

85+ 4.05

2014 2030 2050

Population 78,143,644 87,855,359 90,106,889

THE (in millions) 809,639,185 1,076,654,256 1,351,983,090

Source: Weights based on 2012 U.S. data; reflect each age category relative to the U.S. average


Conclusions

HTP is steadily scaling-up and deepening historically well-known health care system with clear vision of achieving UHC by 2025

In 2.5 years of implementation impressive achievements have been made as approved by two sets of WHO-led independent evaluations

Some programmatic and institutional challenges require urgent attention: sustainable fiscal space, EB service package, NCDs, workforce, etc.


THANK YOU! 20 January 2017

20 january 2017 htp to uhc in iran, aht, tums 2016 · plan for training family physicians and...

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